tag:blogger.com,1999:blog-32087913709244686012018-03-07T12:57:22.088-08:00The Pragmatic PediatricianAlexnoreply@blogger.comBlogger49125tag:blogger.com,1999:blog-3208791370924468601.post-20425522680373746002009-05-06T07:35:00.000-07:002009-05-06T08:03:16.943-07:00The Worried WellDuring this recent H1N1 flu scare, I know many of us physicians have been swamped with patients, both sick and well. It has been a definite challenge, I think for all of us! I am used to seeing a certain number of patients for minor illnesses, and I have come to know which patients tend to be quite ill when they come in versus those who tend not to be. However, this past week or so has been quite different. Although I often find it annoying when parents bring in their children for very minor illnesses, such as a comedone on the nose of a teenager, I have been much more understanding the past few weeks! I had one child come in who was very worried that she was going to die from the swine flu. She had no symptoms, and therefore I didn't use one of our precious few viral swabs to test her for the virus. I tried to reassure her and explain to her the different methods she can use to protect herself from the virus. But I truly felt sorry for her. Her anxiety was palpable when I walked in the room, and I couldn't do anything concrete to assuage her worries. How very frustrating!! She was just old enough to understand the news, but not old enough to fully understand it. I do hope she was able to go back to school and focus on the last few days of the school year, however, I have my doubts. <br /><br />Do we have a way to help these kids besides education? We have mental health providers, but they are usually swamped with patients... I am hoping that next time an illness like H1N1 comes around, we are more prepared either with better training for medical providers to deal with such patients and/or with mental health providers that are dedicated to providing this specialized care.Alexnoreply@blogger.com1http://thepragmaticpediatrician.blogspot.com/2009/05/worried-well.htmltag:blogger.com,1999:blog-3208791370924468601.post-9892969352196134822009-04-24T10:16:00.000-07:002009-04-24T10:45:55.648-07:00turmoil at homeI have had quite a frustrating, sad week. It seems there was a lot of strange medicine being practiced at my local emergency room, including prescribing antibiotics for viruses. But what really wore me down was a family with several girls and boys. All the children came in this week for well-child exams. They are charming, bright, and cute. However, they have been in and out of foster care as their parents have been in and out of jail. I know kids are resilient, but what kind of chance do these lovely girls and boys have of becoming successful adults? They have role models at school and in the community, and, granted, their parents try hard <span style="font-style: italic;">at times</span>, but they don't have much going for them. We are fortunate to have good mental health services here that I've accessed for them; the teachers at the schools do their best to care for them; and protective services is continually involved. I just look at them now and hope and pray that they can overcome the obstacles in their path.Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/04/turmoil-at-home.htmltag:blogger.com,1999:blog-3208791370924468601.post-30553296626796645512009-03-31T22:00:00.000-07:002009-03-31T22:27:18.033-07:00Surprise costsOK, I haven't written in a while, mostly because I've been swamped at work and preoccupied. I'm going to have minor surgery tomorrow, and I'm nervous even though it's no big deal. But now I have to vent.<br /><br />A little background: I'll be having the surgery done at a large hospital which has a busy outpatient surgery center that handles thousands of patients per year, a well-oiled machine. So here's my gripe: I received a phone call <em>today</em> from the billing department of the hospital where I'll be having my surgery, exactly 24 hrs before the scheduled time of surgery. I was told that I needed to pay approximately $1000 tomorrow before I have surgery, the "facility cost" that is not covered by my health insurance, payable by check, cash, or credit card. Now, even though I'm not thrilled about it, I am fortunate enough to have a steady job that provides me with a solid income; I also guessed that I would have to pay something so I was somewhat prepared mentally. What stunned me was that I received so little notice. The surgery was scheduled more than two weeks ago, and I gave the hospital my insurance information at that time. Presumably, I could have been notified shortly thereafter about the fee or even given an estimate of the fees at the time of scheduling. I know many people who would have a hard time paying this large fee. Perhaps the hospital arranges payment plans for those who can't afford a lump sum payment, but I do feel that advance notice is critical and courteous. For those who have a hard time paying, advance notice gives them a chance to speak to family members or their bank about borrowing money, or to put aside money from a paycheck or two specifically for the surgery or to put off making another big purchase. I wonder if it's done like this everywhere. I do know that the same 24 hr notice was given to a member of my staff who had surgery at another hospital just a few weeks ago, which added a lot of stress to an already stressful situation.<br /><br />I think that especially in these challenging economic times, all of us need to be considerate of each other's needs. There, that's my piece. I'll be back online in a day or two to let you know what it's like being a patient, a good reminder for all of us docs around who sometimes forget!!<br /><br />And by the way, <span style="font-size:180%;color:#33ffff;">GO TARHEELS!!!!!</span>Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/03/surprise-costs.htmltag:blogger.com,1999:blog-3208791370924468601.post-90928055437382017472009-03-18T09:54:00.000-07:002009-03-24T15:09:43.747-07:00Will EHR become a reality?I am very excited at the thought that I will eventually have EHR at my office. Sadly, knowing my organization, it will be at midnight on the night of the cut-off, probably in 2015. I have been clamoring loudly for EHR since I started at this job in 2005, as have other physicians in the organization; however, our administration has been resisting, stating start-up costs as the main reason we haven't moved ahead. Now, with money in the national budget set aside specifically for achieving the goal of universal EHRs, perhaps we can start thinking about options.<br /><br />I recently received communication about a website that reviews electronic medical records. I was intrigued, so I checked it out. Software Advice, a website that reviews <a href="http://www.softwareadvice.com/medical/electronic-medical-record-software-comparison/" target="_blank">electronic medical records</a>, makes some interesting points about the future we are facing, with late adopters joining in the fray at the last minute. Will these providers (and organizations):<br /><br /><ul><li>Truly believe in the value of an EHR over traditional paper charts?</li><li>Take a leadership role in advocating adoption of the new EHR in their practice?</li><li>Change their old work flows to match the best practices in leading EHRs?</li><li>Take part in intensive training to learn the new system?</li><li>Ride out the difficult stages of new software adoption and change management?</li></ul>I think that these are valid points, and I will answer each question from my perspective regarding our organization. I think that some of the physicians and mid-level providers do see the value in EHR, but the administration does not. In terms of leadership in advocating for implementation, we have two leaders, our Medical Chief of Staff and our head pharmacist. I think those of us who believe in EHR will be willing to change the way we work, train to learn the new system, and keep working with it until it runs smoothly. I don't think this split will be by age, but rather by comfort level with computer technology. I had the advantage of growing with computers from before they were common (and the hard drive was a cassette player), and although I'm not an expert on computers by any stretch, I enjoy learning new programs. Having worked as a transcriptionist, I'm also a fairly quick typer, so I'm not slowed down by having to use a keyboard vs a pen.<br /><br />They offer a five point plan to help smooth the transition which relates to the five points above. The organization should have a project manager to coordinate the transition from start to finish. I propose that there be two managers, one medical and one technical, because I think that both perspectives are necessary for successful implementation. Next, the team of doctors needs to be rallied, as well as the patients. The transition will hit bumps, and all team members, from the front desk staff to the patients themselves, need to be prepared and understand that EHR will be an excellent solution, eventually. Training will obviously be key. The better the training provided on the program, the more likely the transition will be smooth. So far, I think this will be one of our biggest obstacles, based on the training the staff have received on other new electronic programs, which is none to be exact. Their fourth point is to keep it simple. Amen to that. The transition may need to be gradual, and the EHR will likely evolve as the process goes forward. Finally, the practice will change, be it by medical staff carrying around tablets PCs or by having PCs in the exam rooms. This will require adjustment by medical assistants, nursing, providers, and families. I happen to strongly believe that EHR will be a safer, more efficient way to practice medicine, but I am bracing myself for the transition.<br /><br />I do, however, disagree with the authors of the website on one main point. They feel that EHRs should not be free, that people only value what they pay for. While I see their point, I think that for certain organizations like community health centers, the cost of establishing an EHR is absolutely prohibitive. I know that the money will eventually be re-couped by improved billing and improved efficiency, but the start up capital is a real challenge. In addition, if this is something that is going to be required, at least a subsidy needs to be available to help. Maybe there can be a basic form of EHR which is available free-of-cost to all providers, and then practices that can afford a version with more bells and whistles can pay extra. I don't know if this is the right solution, but it's just a suggestion.Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/03/will-ehr-become-reality.htmltag:blogger.com,1999:blog-3208791370924468601.post-33134449281178651902009-03-06T12:08:00.000-08:002009-03-06T15:32:00.862-08:00Subspecialist shortagesThe news is full of stories about an ever-shrinking group of pediatric specialists, rising average ages of these specialists, and the overall critical situation we are. I also happen to work in a state with a tremendous shortage of doctors, both primary care and specialist care. Needless to say, I spend a fair amount of time thinking about the predicament we are in.<br /><br />The first things that comes to mind as a solution to this problem is to re-examine the current fellowship curricula. It used to be that different fellowships were different lengths, varying from one year to three, depending on the specialty. About fourteen years ago, the American Board of Pediatrics (ABP) made the decision to standardize the length of all pediatric fellowships to three years. I often wonder how much of an impact this has had on the number of graduating specialists. Please don't get me wrong, I think that certain fields require three years of training in addition to the three years of residency, i.e. pediatric intensive care, but others may not. Research plays into this length, I realize, and I know that research funding is very important to post-graduate education programs. When I was checking out the ABP website, I did learn that there is a way to do a fast-track fellowship for those people who already have documented research or other time in the field they're going into. For example, I might be able to do a developmental pediatrics fellowship in <span style="font-style:italic;">two</span> years because I have a master's degree in early intervention. However, this only applies to a small pool of physicians.<br /><br /><br />As a resident, a pediatrician makes approximately $50,000/yr. During this period of training, one is also required to start paying off college and medical school loans; some residents also have families to support . In the current economic crisis, buying a house may not be an option anymore as it has become so much more difficult to get a loan, so one may be paying large sums in rent. Salaries increase a little bit during each additional year of training but not significantly. Then, finally when fellowship training is complete, depending on whether one chooses academic practice vs private practice, one may end up earning less than a private pediatrician and working more hours, and certainly earning less than almost any other type of physician except for family practice. This, after four years of college, four years of medical school, and six years of training. If one were to think of this as an investment, it is not a very high-yielding investment (then again, what is these days?). I know that it's "not all about money," but I feel strongly that time and money are realistic factors that medical students and residents take into consideration. I know this is going to sound cynical, but although passion is wonderful, it doesn't put food on the table.<br /><br />I guess what I'm arguing for is that the ABP reconsider it's decision to standardize all fellowships to three years; what fits one specialty may not necessarily fit all. I would love to see a dialogue on this topic with specialists and generalists alike weighing in. Sadly, I don't know that this is going to happen, as there is so much else going on during these tumultuous times, and hopefully all of us will be focusing on helping President Obama revamp our health care system.Alexnoreply@blogger.com2http://thepragmaticpediatrician.blogspot.com/2009/03/subspecialist-shortages.htmltag:blogger.com,1999:blog-3208791370924468601.post-48796295193280095262009-02-23T10:50:00.001-08:002009-02-23T10:50:26.066-08:001961 electronic medical records<div xmlns='http://www.w3.org/1999/xhtml'><p><object height='350' width='425'><param value='http://youtube.com/v/t-aiKlIc6uk' name='movie'/><embed height='350' width='425' type='application/x-shockwave-flash' src='http://youtube.com/v/t-aiKlIc6uk'/></object></p><p>nearly 50 years later, and where are we?!</p></div>Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/02/1961-electronic-medical-records.htmltag:blogger.com,1999:blog-3208791370924468601.post-85034773672620859392009-02-23T10:18:00.000-08:002009-02-23T10:56:38.916-08:00Feeling a little oldThis past weekend, I started working as a hospitalist, with the goal of working about one weekend per month. I chose to do this to maintain this unique set of skills which I worked very hard in residency to obtain, to see different problems from the ones I see in my outpatient clinic, and to spend some time with other pediatricians. As I was hoping, it was a lot of fun, and it was interesting to see the variety of patients on the pediatric floor. Of course the majority of patients had respiratory problems, it being winter, but even among <span style="font-style:italic;">them</span>, there was some variety. I found my sea legs fairly quickly, to my great relief.<br /><br />I did feel a bit out of touch, however, like I had been passed by father time. When I did my residency, which was not very long ago, we had some parts of the medical record computerized; we were able to look up lab and radiology results online. Every morning, all of us had to walk around the wards, finding nursing notes with vitals, finding charts to write in, and signing verbal orders. This was a great time to check in with patients, parents, and most importantly, nursing, but it was certainly tedious and inefficient! At the hospital where I worked this weekend, most of the medical record has been computerized, and they are in the process of making the ordering process electronic. Needless to say, I was very excited and intrigued to try this new system! It was wonderful to have access to labs, radiology, dictations, and nursing notes on the computer, and actually, on any computer with internet access! What a change! I was pretty slow at using the system since it was brand new to me, but I'm sure that I'll get used to it. But, what was shocking to me was that I missed walking around looking at paper vital signs flow sheets... I was able to talk to the nurses and patients, but it was just different, a little less social. Some aspects were much better, like the graphs with the fever curve and computer-calculated ins/outs which eliminate relying on my math skills (a positive), and the previously hand-written narratives which were now legible! Yet, it made me feel a little old that I missed the old paper system. I can't imagine what it would be like for someone to learn this system without any experience with electronic records! Obviously, electronic health records are the future (in some places, the present!), and this change will likely change the medical culture, just as mp3s have changed the music culture. And, I suspect, just like LPs have a strong following even now in 2009, I suspect paper charts will have a strong following in 2020, but I, for one, will be relieved when I get EMRs in my office and the hospital EMR continues to progress.<br /><br />I found an amazing video on YouTube from 1966 that I posted on my next blog. Please check it out!Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/02/feeling-little-old.htmltag:blogger.com,1999:blog-3208791370924468601.post-54590677695543651632009-02-04T13:17:00.000-08:002009-02-04T15:06:58.491-08:00You want passion? Let's talk food!!!<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://3.bp.blogspot.com/_wYVtLuqwDX8/SYoYYv3M47I/AAAAAAAAACk/kCWfOq97lGQ/s1600-h/pig.gif"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 200px; height: 120px;" src="http://3.bp.blogspot.com/_wYVtLuqwDX8/SYoYYv3M47I/AAAAAAAAACk/kCWfOq97lGQ/s400/pig.gif" alt="" id="BLOGGER_PHOTO_ID_5299074724998734770" border="0" /></a><br />I can't stand it anymore. I read my own blog, and I fall asleep... Health care, costs, access, blah blah blah. I like to write about things I'm passionate about. And I generally am passionate about my job, except for this time of year, when I feel like I'm drowning in boogers. Although some of my patients happily eat their little green boogers, I'd rather dine on other snacks!<br /><br />I was raised in a family where we ate dinner together every night, we had a salad every night, and we had dessert usually when we had company. Dinner was a fun, chatty event, and we kids helped cook and clean up afterward. Our father cut the bread, and, I believe, that was it for him! But my mother was an excellent cook. I learned to taste unusual foods that my parents enjoyed, including pig brains, mountain oysters, and tripe. I didn't necessarily like them all, but I did acquire a taste for at least trying anything once. Some things, like avocados, I hated as a kid and learned to love as an adult; others, like tripe, I still don't like. Yet, my parents' love of food and dining with family and friends was definitely passed on to all of us kids.<br /><br />These days, I travel to eat. I exercise to eat. I dream of food. When I go somewhere, I try to research where I can eat interesting food. Sometimes, the best restaurants are ones we find by accident. Ethnic food is my preference, although this past Sunday, I had one of the best hamburgers I've ever eaten in my life in Coronado, just across the water from San Diego, at The Burger Lounge, <a href="http://www.burgerlounge.com/">www.burgerlounge.com</a>. I didn't think I was hungry when I entered the restaurant, but I didn't have any difficulty eating my burger and some outstanding fries. When it comes to eating ethnic food, Ethiopian is probably my favorite. I still remember the first time I ate at an Ethiopian restaurant - it was called The Blue Nile, as many are, and it was in Durham, NC. We ate at a traditional table with the woven basket, drank some delicious tej, and ate a wonderful variety of vegetarian dishes on the traditional bread, injera. From then on, I started to seek out such restaurants on my travels. One of my all time favorites is in Berkeley, called FinFine, <a href="http://www.finfine.com/">www.finfine.com</a>. The kitfo, an Ethiopian-style steak tartare, is outstanding, if you enjoy raw meat.<br /><br />However, if we're talking passion, I need to talk about barbecue in North Carolina. Now, when my family moved there from New Jersey, I thought that the word barbecue was a verb or an adjective, but definitely not a noun. So, needless to say, when I was offered barbecue at our school cafeteria, I asked, in all innocence, "barbecued what?" The lunch lady looked at me strangely and answered, "barbecue." I politely repeated my question, and she politely repeated her answer. Just as an aside, there weren't many northerners in Winston-Salem at that time, and I think she thought I was as strange as I thought she was. Eventually, when I asked what kind of meat it was (remember, it was a school cafeteria, so color is meaningless, it's all the same shade of brown, even the chicken), she said pork, so I happily ate it. Not long after, our next door neighbor invited me to go with her to Lexington, NC, home of "western" barbecue and the famous Lexington Barbecue festival, <a href="http://www.barbecuefestival.com/">www.barbecuefestival.com</a>. This type of barbecue uses a ketchup-based sauce and only the pork shoulder; eastern barbecue uses the whole hog and a vinegar-based sauce. Both kinds are cooked over an open pit, traditionally with wood fires. Anyway, we ate at one of the famous old restaurants, and I liked the hush puppies, but I wasn't crazy about the barbecue. So, at this point in my young, naive life, I simply thought I didn't like barbecue much because I didn't like the tomatoey, sweetish sauce. Then, about four long years later, I saw the light, and it was in Goldsboro, North Carolina, home of Wilber's, <a href="http://www.wilbersbarbecue.com/">www.wilbersbarbecue.com</a>. The pulled pork was out of this world juicy, tasty, smokey, and had a wonderful zing from the vinegar-based sauce. That was it! I done been converted that very day, as some people around there might say. The restaurants along US 70, starting with Ken's in La Grange, going all the way to the coast, are all pretty safe bets, with some, like Ken's, being better than others. If you get a chance to go, remember to ask for "outside brown," which means the pieces of meat that are closest to the fire and have a crispy side. Better yet, try to get in on a real pig pickin' at someone's house. And ask if you can get there at 4am when they start the hog cooking. It is a slow, careful process, with lots of basting and stoking of the fire, and, as often happens when men stand around a fire for many hours, a fair bit of beer gets consumed! If I've managed to pique your interest in this delicacy and in the debate between the east and the west, check out this website: <a href="http://hkentcraig.com/BBQ.html">http://hkentcraig.com/BBQ.html</a>. And please, as bumper stickers in eastern NC say, keep your maters off my pig!! I now have to wipe the drool off my keyboard and go and plan my next culinary adventure. Bon appetit!!!Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/02/you-want-passion-lets-talk-food.htmltag:blogger.com,1999:blog-3208791370924468601.post-1809491367026156572009-01-29T16:00:00.000-08:002009-01-29T16:15:59.961-08:00Economics, job lossesLast week, I had the pleasure of watching the inauguration of our 44th president. I felt optimistic about our future, even though President Obama's speech was not full of the optimism he expressed during the campaign, rather full of realism. I know the economic disaster we have on our hands, as well as the diplomatic one, the wars we are fighting and some might say losing. Yet, I am basically a glass half-full kind of a person!<br /><br />However, I am really starting to see the effects our economy. On the news this morning, there was more disturbing news about record job losses, record company closures, etc. In my community, there always seems to be a recession with few good-paying jobs, expensive gas and groceries, and a lot of elderly people with limited incomes. But now, we are seeing an influx of people from elsewhere in the country who have lost their jobs. They move here because housing is still inexpensive, and the weather is nice. I guess if you're going to be unemployed, at least it's nice to sit in the sunshine. But really, it's shocking to realize the numbers of people moving from industrial cities like Detroit, Minneapolis, Pittsburgh. The problem is that there are, like I said before, few good jobs.<br /><br />I was speaking with a drug rep who survived large cuts at his company, only to be given a larger area of NM to cover. He is very grateful that he has a job, even if it means he doesn't see his family. I also now see several fathers in my clinic who are back home, having lost their jobs in the oil fields, suddenly becoming reacquainted with their wives and children, but jobless. I'm also seeing a rise in kids entering the military after high school because college is unaffordable.<br /><br />It's just very different when you know people directly who are suffering from our economy, rather than only hearing about it on the news. I hope that our new president and congress can come together to create jobs, to improve education, and to improve our health care system. Sadly, I don't think there is a quick fix, even a great big economic stimulus package. I know that I'll just continue to take care of the families in the community; at least I can do that to a degree, whether they have health insurance or not!Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2009/01/economics-job-losses.htmltag:blogger.com,1999:blog-3208791370924468601.post-22076491252176941782009-01-16T10:26:00.000-08:002009-01-16T12:32:42.725-08:00Lab feesAs winter is progressing, I am getting busier, as are most pediatricians. It's amazing the difference between June and say, January or February, numbers. I appreciate my slower days in the summer, but I have to say that winter days in the office simply tend to fly by!<br /><br />However, this winter is going to be a bit different. I've mentioned in a previous blog that our clinic now requires patients to pay for labs at the time they're done if they don't have any health insurance. This is awkward and annoying to me to have to explain that I want a particular test done, and, by the way, that will cost you ten bucks! I have the power to waive the fee if the family cannot pay, and I document exactly why the test is required. Yet, when I do this, there are many phone calls back and forth between our main office and my office to find out exactly why the fee was not paid. I could go on about this, but I've already complained about it in a previous blog. <br /><br />Today, what brought this back to the forefront of my thoughts was that I had to ask a family to pay for a test, and I also happened to read another blog about lab fees: <a href="http://thecountrydocreport.wordpress.com/2009/01/15/the-price-is-right-country-doc-style/">http://thecountrydocreport.wordpress.com/2009/01/15/the-price-is-right-country-doc-style/</a><br />I was shocked to see the prices he posted for labs. I had been told by the powers that be that we got a special rate for our labs and that we did not have to charge the administrative fees. So, just to show the stark differences, here is a list of some our fees, without the additional administrative fees: (admin charge is approx $10.)<br /><ol><li>CBC (complete blood count with differential): $2.70</li><li>BMP (basic metabolic panel): $2.70</li><li>CMP (comprehensive metabolic panel with BMP): $2.76</li><li>PSA (prostate specific antigen, a test for prostate cancer): $7.20</li><li>TSH (thyroid stimulating hormone, a test for monitoring thyroid disease): $ 3.60</li><li>Lipid panel: $2.58</li><li>Urine culture: $6.00</li></ol>The most expensive test on our basic listing is a hepatitis C RNA PCR for $181.20. Now, you can see an enormous difference in the costs I've listed versus those listed by the Country Doc. Why is there this difference? Admittedly, one needs to add $10 to the fees I've listed, and the rates I've listed have been negotiated for a large group of 8 health centers. In addition, the lab company is willing to accept some loss with uninsured patients, but this cost gets passed on to those with insurance. On a side note, it would be interesting to see what that particular lab charges insured patients for the same labs. But why is there so much difference between the two labs? Again, it brings to mind the problems we have with our health care system. Imagine saving $12 on each CBC that is drawn throughout the US - if 1/3 of the US population of ~305 million received one CBC per year, that would add up to 1.2 billion! I'm sure it's the same with the pharmaceutical companies and saving $12 per script written in the US would also add up.<br /><br />I'm just hoping, come January 20, that the debate on healthcare will start up with actual results this time. I do know that SCHIP is already being re-addressed and will not be vetoed by the new president, so I have hope.Alexnoreply@blogger.com3http://thepragmaticpediatrician.blogspot.com/2009/01/lab-fees.htmltag:blogger.com,1999:blog-3208791370924468601.post-11765768547422478602009-01-05T08:27:00.000-08:002009-01-05T09:38:52.984-08:00New Year's Resolutions/Wishes<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_wYVtLuqwDX8/SWJDe1jit_I/AAAAAAAAACQ/6z4x88EesNI/s1600-h/PIXIDUST.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 113px; height: 145px;" src="http://2.bp.blogspot.com/_wYVtLuqwDX8/SWJDe1jit_I/AAAAAAAAACQ/6z4x88EesNI/s320/PIXIDUST.jpg" alt="" id="BLOGGER_PHOTO_ID_5287863109537675250" border="0" /></a><br />Happy New Year to everyone!! Now that the holidays are over and school is back in session, my life is returning to it's usual busy wintertime schedule. It's also the time of year when people discuss their resolutions for the new year, and I see a lot more people walking on the track after work! I've often been tempted to ask if they are there to lose weight in the new year, but instead I just see how many days they last...it seems that two weeks is about the maximum. All this aside, it's also a special January this year, as we will be inaugurating a new president in a few short weeks. I hope things will start to change quickly.<br /><br />In light of the potential for change, I have come up with a list of my top 10 wishes for our health care system which I am hoping will be targeted for change early in this new administration. I know that some of these wishes are not free, and I don't know where the money will necessarily come from, but a wish is just that, a wish! I could also go on with many more wishes, but I think ten is a good start.<br /><br /><span style="color: rgb(255, 0, 0);">1. Renew and increase funding for SCHIP. Perhaps with more Democrats and more progressive Republicans in Congress, this will happen.</span><br /><br /><span style="color: rgb(51, 204, 0);">2. Increase reimbursement for pediatricians giving vaccines.</span><br /><br /><span style="color: rgb(51, 51, 255);">3. When considering universal health care, examine what other countries have done and perhaps create a system which combines the best from the different approaches being used world-wide. Having waited this long to do what most other first-world countries have already done, we might as well turn this to our advantage and learn from the mistakes of others.</span><br /><br /><span style="color: rgb(255, 102, 0);">4. We, as physicians, need to practice medicine responsibly. We need to accept that we are contributing to the skyrocketing costs of medical care in the US, and we need to do something about it.</span><br /><br /><span style="color: rgb(102, 0, 204);">5. Continue to encourage medical students to go into primary care with increased emphasis on programs that already exist, such as the National Health Service Corps. As costs for higher education continue to escalate and funding for student loans is cut, informing pre-med college students about the availability of scholarship programs may be more effective than in the past. </span><br /><br /><span style="color: rgb(255, 0, 0);">6. Continue to study pharmaceuticals specifically in the pediatric population.</span><br /><br /><span style="color: rgb(51, 204, 0);">7. Continue to promote the safety of vaccines. The American Academy of Pediatrics is working diligently on this effort.</span><br /><br /><span style="color: rgb(51, 102, 255);">8. Strive to continue research efforts with stem cells.</span><br /><br /><span style="color: rgb(255, 102, 0);">9. Provide adequate reimbursement for obesity counseling, nutrition education.</span><br /><br /><span style="color: rgb(153, 51, 153);">10. Let's get daily physical education back in schools!!</span>Alexnoreply@blogger.com2http://thepragmaticpediatrician.blogspot.com/2009/01/new-years-resolutionswishes.htmltag:blogger.com,1999:blog-3208791370924468601.post-33958291111592044842008-12-19T09:06:00.000-08:002009-01-05T11:31:27.466-08:00MRIs as screening toolsI have really come to enjoy the world of blogs! I was doing a little catch-up reading today of several that I enjoy, and I found a disturbing bit of news on one of my favorites, <a href="http://thecountrydocreport.wordpress.com/2008/11/23/today-show-plugs-mri-screening-for-brain-tumors/">http://thecountrydocreport.wordpress.com/2008/11/23/today-show-plugs-mri-screening-for-brain-tumors/</a>. This show was aired on 11/17. I don't watch the Today Show, as I tend to get my news online and on NPR, and somehow I missed this story.<br /><br />Briefly, it appears that there is a push to use MRIs as a screening tool for brain tumors. As the Country Doc points out in his excellent discussion, there are no data supporting this type of use of MRIs. I'm just appalled at the Today Show for airing such a piece! I realize that the mobile MRI traveling around NYC was only charging $169, but that is not a realistic price, just like no-money down house financing...<br /><br />Our health care system is in shambles; we outspend every other country in the world, yet we have worse outcomes than most 1st-world nations. It seems that finally we may get universal health care, but if it is going to work, we need to make some difficult choices. Fortunately, we have established a few evidence-based guidelines we can use to help make decisions, but we need to use them. There are also studies from foreign countries we can use to help guide us. Please don't get me wrong, I am grateful to live in one of the most scientifically innovative and creative societies! And I do worry that if/when we cut health care spending, some of it will come out of research funding. However, we need to take responsibility and use our limited funds wisely. Perhaps if we place more emphasis on <span style="font-style: italic;">preventive</span> care, we'll avoid some of the huge costs of preventable diseases. I know I'm not saying anything remotely new, but I feel strongly that our American mindset needs to change; in other words, we may not be able to save every life regardless of cost, we may not be able to give every single citizen access to the newest, most expensive, and not necessarily the best drugs! As a medical provider, I share in this responsibility, and it is a heavy burden. I went into the medical field because I like to fix things, make people better, but I too need to accept that there are limits.Alexnoreply@blogger.com2http://thepragmaticpediatrician.blogspot.com/2008/12/mris-as-screening-tools.htmltag:blogger.com,1999:blog-3208791370924468601.post-31749735091359905862008-12-10T07:43:00.001-08:002008-12-17T13:18:15.650-08:00The DesertI grew up on the East Coast, and I always loved all the trees, all the green, the lush green lawns. I also remember driving from Flagstaff down to Tucson for the first time, thinking how brown and dreary the desert was. Shortly after arriving in Tucson, I visited the botanical gardens and started my education about the desert. Slowly, I began to learn the names of desert plants, such as creosote, mesquite, and ocotillo. The more I learned, the more variety I started to see in the landscape. Where I'm going with this is that I have come to love the desert and see more colors in it than in the green landscapes of the east.<br /><br />Last year, on Christmas Eve, we camped out on the dunes of White Sands National Monument, under a full moon. We were the only ones camped in the park and were utterly alone in the vast expanse of the stunning gypsum sand dunes. The silence was deafening, the light was breathtaking, and the air was sharp. Although we were quite cold, it was one of the most incredible camping experiences I have ever had!<br /><br />I decided to look up some poetry about the desert to share with my readers, hopefully conveying some of it's beauty and loneliness and power. Enjoy!<br /><br /><br /><div style="text-align: center;"><span style="font-weight: bold;">The desert has many teachings</span><br /><br />In the desert,<br />Turn toward emptiness,<br />Fleeing the self.<br /><br />Stand alone,<br />Ask no one's help,<br />And your being will be quiet,<br />Free from the bondage of things.<br /></div><p class="MsoNormal" style="margin: 0cm 0cm 0pt;"> </p><p class="MsoNormal" style="margin: 0cm 0cm 0pt;"><br /></p>This is an excerpt from a poem is by Mechthild of Magdeburg, a German mystic from the 13th century. Although she did not live in a desert, and the desert in this poem is likely not a physical desert, I feel that these first two stanzas of this poem captures the spirit of being in a desert.<br /><br />The following is a poem by Lord Byron which appealed to me as well!<br /><br /><div style="text-align: center;">Oh that the desert were my dwelling place,<br /></div><div style="text-align: center;">With only one <span class="highlightedSearchTerm">f</span>air spirit <span class="highlightedSearchTerm">f</span>or my minster.<br /></div><div style="text-align: center;">That I might <span class="highlightedSearchTerm">f</span>orget the human race,<br /></div><div style="text-align: center;">And hating no one, love her only.</div><br /><br /><div style="text-align: left;">This next poem is by Bernard Howe, a poet who lives in Tucson, which is part of the Sonoran desert, quite different from the Chihuahuan desert where I live. It is lighthearted and quite descriptive of the terrain.</div><br /><br /><div style="text-align: center;">Way out west where the prickly pear grows,<br /></div><div style="text-align: center;"> lived an old man who only had 9 toes.<br /></div><div style="text-align: center;"> Seems a javelina wanted one for lunch,<br /></div><div style="text-align: center;"> when it got the chance it took it with a munch.<br /></div><br /><div style="text-align: center;"> Life in the desert is different from the city,<br /></div><div style="text-align: center;"> for out in the sonoran no one gives you pity.<br /></div><div style="text-align: center;"> With the hot sun beating down upon your head<br /></div><div style="text-align: center;"> if you run out of water the next thing is your dead.<br /></div><br /><div style="text-align: center;"> The snakes are hiding quietly amongst the desert rocks,<br /></div><div style="text-align: center;"> if your not to careful one may bite you through your socks.<br /></div><div style="text-align: center;"> And if that ain't enough there's scorpions that will sting,<br /></div><div style="text-align: center;"> then there's monsoon storms that always come in spring.<br /></div><br /><div style="text-align: center;"> Yes that old sonoran desert that runs through the southwest,<br /></div><div style="text-align: center;"> is home for me old sam the old man thats possessed.<br /></div><div style="text-align: center;"> The desert cactus that flowers are pretty to your view,<br /></div><div style="text-align: center;"> but if you step on one, the thorn goes through your shoe.<br /></div><br /><div style="text-align: center;"> It seems everything grows wild within this here desert,<br /></div><div style="text-align: center;"> along with the critters that make sure you stay alert.<br /></div><div style="text-align: center;"> But there is still beauty in all of this here land,<br /></div><div style="text-align: center;"> like the setting of the sun which is always grand.<br /></div><br /><div style="text-align: center;"> Many colored wild flowers cover everything in spring,<br /></div><div style="text-align: center;"> the splendor of a sunset which makes your heart just sing.<br /></div><div style="text-align: center;"> Yes mother nature protects all that she has made,<br /></div><div style="text-align: center;"> and all that lives out here knows where to find the shade.<br /></div><br /><div style="text-align: center;"> Yes the desert sage may dry up and become a tumbleweed,<br /></div><div style="text-align: center;"> and with a dust devil they can pick up lots of speed.<br /></div><div style="text-align: center;"> The road runner runs along like the quail with her young,<br /></div><div style="text-align: center;"> and our Native American brothers speak another tongue.<br /></div><br /><div style="text-align: center;"> All these things live in harmony along with mother earth,<br /></div><div style="text-align: center;"> I hope nothing destroys this for it is beyond any worth.<br /></div><div style="text-align: center;"> God made this desert land with all its natural beauty<br /></div><div style="text-align: center;"> and we must protect its balance because it is our duty.</div><br /><br /><div style="text-align: left;">The final poem is one that I wrote. Now I put it at the end, with the hopes that my readers don't actually get to it...Poetry is not a strength of mine, and I've probably broken every rule/convention in writing it. It is about White Sands National Monument.</div><br /><br />Vast and undulating<br />Glistening and rippled<br />Interrupted by lone yucca<br /><br />The power is overwhelming<br />The silence roars<br /><br />I am alone in the vastness<br />My footsteps are my only past<br />Adjacent dunes are my only futureAlexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/12/desert.htmltag:blogger.com,1999:blog-3208791370924468601.post-82072563703253670792008-12-05T15:39:00.000-08:002008-12-05T15:52:42.363-08:00ConnectionsI've been a bit slack with blogging through the holiday, enjoying a break from work, then coming back to a flood of phlegm!! You know how it is when you take off of work, you end up paying for it in spades.<br /><br />I live in a fairly small town in a state that is not known for it's good schools. I myself was fortunate enough to grow up in areas with excellent public schools, and this was primarily due to my parents' choices of where to live; they sacrificed a lot for us to be able to go to good schools. I also enjoyed school and did pretty well. <br /><br />Sadly, it seems that a lot of the high school teenagers here are not particularly ambitious and don't work very hard. For example, the first year we lived here, there was no valedictorian in the graduating class because no one had fulfilled the requirement of taking at least three honors classes in four years of school. This was stunning to hear. However, this week I had the pleasure of interacting with a junior who I could identify with a little better. She loves school, is taking the hardest classes she can possible take, and wants to go to college. She hates to miss school, and she feels stressed when she gets behind. It was just such a pleasure to chat with her about school and AP classes! When I saw her a couple of days ago, I felt like we really connected. Today, she came in to see me for some mental health issues, and she was really able to articulate her feelings, and so I felt like I could help her in a way that I can't the teens who simply grunt!<br /><br />Seeing her reminded me that I do enjoy working with teenagers, I love the conversations, I like listening to their thought processes, I like hearing about their plans for the future. Sometimes I lose sight of this when I have less meaningful interactions, but I was pleasantly reminded today with my last patient of the day.Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/12/connections.htmltag:blogger.com,1999:blog-3208791370924468601.post-91366903413667041222008-11-20T08:14:00.000-08:002008-11-20T09:37:07.079-08:00Paying for labsLast month, we received news at my clinic from "the bosses" that we were to use only one particular lab company for all our labs except for a few types of private insurance. This news came as a surprise, and the medical providers had not been asked for any input on choosing the company. I was very disappointed, as the one that was chosen just happened to be one of the slowest in processing times. When I questioned the administration about the decision, I was told that they offered our organization the best prices for our uninsured patients. End of discussion. Since there was nothing I could do to change the decision, I tried to improve the speed of processing through our customer service representative. Needless to say, nothing has changed on that front either.<br /><br />So, I went about my business, grateful each time when I had a patient who had the kind of insurance which allowed us to use a different company. But, then, last week, bammm!!! out of the blue, another dictum. This lab company who had contracted to take on the organization's uninsured patients decided that they were losing too much money on us; understandably, they cannot do thousands of labs for free. And our organization decided that we cannot keep losing money by writing off the bad debt. Keep in mind that we are a group of federally-funded community health centers (CHCs), so we provide healthcare for any and all, regardless of insurance status. The policy on labs now has changed, and our patients who don't have health insurance have to pay cash up front for labs. As a provider, I do have the ability to say that a particular lab must be done, regardless of the ability of the patient to pay. However, someone from my staff has to inform the family of the cost of the lab, ask if they can afford to pay, then let me know if they can or can't, and then I need to note in several different places whether the lab is critical or not. I already try not to do unneccesary labs on my patients since for most kids a blood draw is very frightening, so when I order a test, it is generally very important! I suppose I am disappointed because I chose to work for a CHC so that I could provide care to all. I already have to choose medications by whether they are covered or not by each particular Medicaid program, I often have to get prior authorizations for medications and radiologic procedures!<br /><br />I am very bothered and saddened by this new policy. Many of the families in this community are already struggling to make ends meet. My worry is that they will stop coming in when word gets out about this policy. Fortunately, most of the children I see are covered by Medicaid, but there is a fairly large population of adults who can't afford health insurance. I also understand that our organization cannot continue to provide essentially free care indefinitely. The patients know that we do not send out bill collectors, and some of them have large unpaid bills. However, if they can come in for preventive healthcare, which sometimes includes labs like lipid panels, we end up saving money on them in the long term. I really don't know what the solution is, except that we need to address the healthcare crisis immediately.<br /><br />Along those lines, I happened to come across the blog of the country doc, Dr. Cohen, discussing President-Elect Obama's choice of Tom Daschle for head of the Department of Health and Human Services, which seemed quite relevant to me, as I continue to struggle with this new policy. I admire Mr. Daschle, but like Dr. Cohen, I am concerned that he may not truly understand what is going on the ground level of healthcare. Both Mr. Daschle and his wife have ties to healthcare firms. Now, I know that healthcare firms are not inherently evil, but they are businesses which want to make money. I'm also not against making money, but I think that sacrifices will have to be made on everyone's part. I am simply hoping that Mr. Daschle will seek input from all participants in our broken healthcare system, including families, primary care physicians, specialists, pharmaceutical companies, and health insurance companies. We need a comprehensive team approach if reform is going to succeed. As a country, we have a lot on our plate right now, and I frankly don't envy Mr. Obama's position one tiny bit!Alexnoreply@blogger.com2http://thepragmaticpediatrician.blogspot.com/2008/11/paying-for-labs.htmltag:blogger.com,1999:blog-3208791370924468601.post-50547117616568746652008-11-14T12:31:00.000-08:002008-11-14T15:36:12.241-08:00Brain PowerWhen I was eleven years old, one of my cousins had an aneurysm which left him a quadriplegic. He had been in medical school, was an avid mountain climber, and an outstanding violist. He had had some non-specific neck pain for a couple of days, and one night, it was bad enough that his mother took him to the hospital. The short story is that he went to the operating room with the hopes that the aneurysm could be repaired but woke up paralyzed, on a ventilator. This really impressed me, as he could speak, but he had to use a computer to write, using his tongue to move a cursor. Ever since then, I have been afraid of a similar thing happening to me, especially after learning about multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) a few years later. Of course, when I was a first year medical student, I had every disease we learned about, including MS and ALS! Fortunately, I survived intact.<br /><br />For those of you who may not know what ALS is, it is a rapidly progressive and always fatal disease which attacks the nerve cells that control voluntary motor function. Eventually, the upper motor neurons (those in the brain) and the lower motor neurons (those in the spinal cord) stop working, so messages do not get transmitted to muscles, and the muscles eventually shrink and waste away. Oddly enough, most patients retain control of bladder and bowel function, eye muscles, and the senses of smell, taste, hearing, and touch. Usually patients die within three to five years from the onset of the diagnosis, although approximately ten percent live for ten or more years. For more information, I found the website from the National Institute of Neurological Disorders and Stroke to be very informative.<br /><br />These memories of worrying about various illnesses came back to me last week when I watched the CBS news show, Sixty Minutes. There was a segment called, "Behind the Scenes: Brain Power" (<a href="http://www.cbsnews.com/stories/2008/11/04/60minutes/main4570731.shtml">http://www.cbsnews.com/stories/2008/11/04/60minutes/main4570731.shtml</a>) which just blew me away. It focused on a neuroscientist by the name of Scott Mackler from the University of Pennsylvania. He was diagnosed with ALS, and the disease has progressed to where he is ventilator-dependent and unable to speak. However, he is now able to communicate using Brain Computer Interface Technology, which basically allows a person's brain to be connected to a computer using EEG electrodes attached to a cap which is placed on his skull. So, in order to write a letter or to speak, Dr. Mackler looks at a computer screen with flashing letters, and the computer writes the letter that he is thinking of. Absolutely amazing!! The neuroscientist who was "locked in" by his disease now can write journal articles and goes to work in his lab where he conducts research. The story also talks about a woman, Cathy, who suffered a brain stem stroke which left her only able to move her eyes and with some facial expression. She volunteered to participate in a clinical trial where the Braingate system was implanted directly into the motor cortex of her brain. Cathy is able to move a cursor on a computer screen by thinking about how she would move her hand; she is able to turn off lights, for example, using this technology.<br /><br />Advances in the science like this are always so exciting to me. Yes, I'm a nerd, I know. But the potential for this Braingate technology is limitless, and there are so many people who could benefit from this. Obviously, it would be even better if we could find the causes of neurodegenerative diseases so that we could prevent them, but even if we did, it could be used for stroke victims, accident victims, and many others. I am concerned that with our healthcare system in shambles, along with our economy, that funding for research will be cut, but I hope that our amazing, creative, dedicated science community can continue to thrive somehow.Alexnoreply@blogger.com1http://thepragmaticpediatrician.blogspot.com/2008/11/brain-power.htmltag:blogger.com,1999:blog-3208791370924468601.post-83275785817415828972008-11-07T10:38:00.000-08:002008-11-07T14:44:37.157-08:00I'm back! It's been a busy few weeks since I last wrote, between an onslaught of strep throat infections at work and the election, I'm utterly exhausted! Even though the election was decided fairly early on Tuesday evening, I was up too late because I was too stirred up to go to sleep. I was so excited but also apprehensive about our future as a country. Anyway, I'll stop talking about the election, since I have no new and/or amazing insight to add to all the discussion, except that I am very proud of the people of the United States.<br /><br />On a completely different note, I had a patient this week that reminded me of Stuart from MadTV. For those of you who don't know what I'm talking about, here it is:<br /><br /><a href="http://www.youtube.com/watch?v=U02xbYhhjxQ">http://www.youtube.com/watch?v=U02xbYhhjxQ</a><br /><p>My patient was a little younger, fortunately, and I was not thrown out of the window, only because we don't have windows in our exam rooms. But his mother just stood there and watched, then reinforced his behavior by comforting him. She then proceeded to threaten him with a shot if he wasn't good, asking me to back her up on that!! The boy had already dismantled the exam room and managed to pull down almost all the stickers off of our sticker boxes...all this within the first few minutes before I even walked in. The first thing he did, actually, when he arrived at my office, was set off the fire alarm in the patient bathroom. As soon as the alarm went off, I knew he had arrived - it's one of his favorite things to do!</p><p>This boy can be well-behaved, I've seen it. When he comes in with his grandmother, he's fine. We've come to an agreement with the physical exam: he holds the stethoscope for me on his chest, I hold it when I listen to his lungs; he holds the otoscope with my hand on his, same goes for the ophthalmoscope. So, needless to say, when I see how he behaves with his mother, it frustrates me. When I ask her about it, she explains to me that his feelings get hurt when she disciplines him, so she's given up. I offered her a session with our social worker to help her understand how she can be her son's friend but also his mother...she was interested, now we just have to see if she shows up; until then, I can only hope that he comes with his grandmother!</p><p>We all have our Stuarts, be they children or adults. Sometimes we can work with them, sometimes we can't. They can be difficult to examine, and I always worry about missing something, a murmur for example, when I have one of these wild screaming ones. But, when I'm ready to pull my hair out, I just think about Stuart, and I start to laugh, and think, in his voice, "I can do it...."</p>Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/11/im-back-its-been-busy-few-weeks-since-i.htmltag:blogger.com,1999:blog-3208791370924468601.post-33199020668829677452008-10-21T09:31:00.000-07:002008-10-21T10:22:06.739-07:00ADHD and Nature WalksI was perusing the NY Times today when I came across an article on Tara Parker-Pope's blog on wellness about a small study conducted at the University of Illinois at Urbana-Champaign about nature walks for children with ADHD.<br /><br />Here is a quote from her blog which can be found at <a href="http://tinyurl.com/5lqqhm">http://tinyurl.com/5lqqhm</a><br /><br /><blockquote>"A small study conducted at the University of Illinois at Urbana-Champaign<br />looked at how the environment influenced a child’s concentration skills. The<br />researchers evaluated 17 children with attention deficit hyperactivity disorder,<br />who all took part in three 20-minute walks in a park, a residential neighborhood<br />and a downtown area.<br /><br />After each walk, the children were given a standard<br />test called Digit Span Backwards, in which a series of numbers are said aloud<br />and the child recites them backwards. The test is a useful measure of attention<br />and concentration because practice doesn’t improve the score. The order of the<br />walks varied for all the children, and the tester wasn’t aware of which walk the<br />child had just taken.<br /><br />The study, published online in the August The<br />Journal of Attention Disorders, found that children were able to focus better<br />after the “green” walks compared to walks in other settings."</blockquote><a href="http://tinyurl.com/5lqqhm"></a>I did not find this discovery to be at all surprising. This was a suggestion given to me when I was diagnosed with ADHD, and it's one I always recommend to parents. Whether a child is on medication or not, I recommend twenty to thirty minutes of outside play immediately after school before homework. Unfortunately, not all parents seem to believe me that it works. I am happy to have a study, be it small, to quote, rather than only my own experience. <br /><br />For myself, I have learned that I am able to focus much better when I get home when I have gone for a run, once I recover a little...To help motivate myself, I like to sign up for races, it gives me something to work towards; if I don't, then I can come up with one hundred excuses not to exercise on any given day! I cherish my runs outdoors, breathing in the fresh air, having quiet time without interruption, and working my muscles. I also get a mental boost from the sense of accomplishment.<br /><br />On a different note, I worry about "kids these days," to sound like an old lady. Most of them have such busy schedules, going from school, to soccer, to music, home or out for dinner, then homework. Does anyone play kickball on the street anymore after school? Does this over-scheduling have something to do with the increase in the diagnosis of AHD? I also wonder what happens to some of these kids when they get to college, and suddenly they are in charge of their time after classes. Do they know how to allocate their time wisely? I don't know, but I'd love to hear from some readers!Alexnoreply@blogger.com3http://thepragmaticpediatrician.blogspot.com/2008/10/adhd-and-nature-walks.htmltag:blogger.com,1999:blog-3208791370924468601.post-28743516863014982322008-10-17T09:07:00.000-07:002008-10-17T10:39:23.758-07:00last debateTwo nights ago, I watched the last debate, more out of curiosity than a notion that I might hear something new; I wanted to see how Sen. McCain behaved in light of his declining popularity. Sure enough, neither candidate said anything particularly new and exciting, and each one responded to the other in much the same way they had in the previous debates, one with an awkward chuckle, the other with utter calm and poise.<br /><br />However, I, along with Orac, a fellow blogger (see <a href="http://tinyurl.com/4a695j">http://tinyurl.com/4a695j</a>), was puzzled by McCain's discussion of autism. Orac, along with others, felt that this was pandering to the "autism-vaccine" people, as well as an attempt to make up for previous incorrect statements about vaccines. I suspect that this is true. But what I found particularly strange was this focus on Gov. Palin's understanding of autism...because she has a child with Trisomy 21? Or does McCain get the two diagnoses confused? They couldn't be more different! I realize that children with autism and with Trisomy 21 both are considered to have special needs but to assume that a parent of one is an expert on the other just doesn't make sense. Maybe he didn't realize that this discussion which he inserted into a statement about reform (and again, how is this related???) would cause a negative stir.<br /><br />Both as a pediatrician and as a former early interventionist, I am extremely interested in education, including early childhood, special education, and regular education (if you can call it that!). I have been listening carefully to what the candidates have been saying about this. Wednesday night, Sen. McCain proved again to me that he doesn't know much about the topic and that he doesn't really care much about it. Although Sen. Obama hasn't spoken a lot about special education, I am thrilled with his interest/belief in early childhood education. Sadly, with a rotting economy and the "war on terror" to pay for, I don't know how much can truly be done about it, but I think it is a wise investment, even in this economic state. I like Sen. Obama's idea of getting parents more involved, although I don't really know how he can enforce that. But, how can we continue to be a world leader if our educational system is in a similar state to our economy? Certainly, a spending freeze would do nothing for the state of education, it might even diminish Gov. Palin's ability to get early intervention services for her son....Now I'm rambling, so I'll stop. We all know that our future president has an enormous task in front of him (or her, heaven forbid) and will likely not be able to accomplish all his goals, I just hope that the vision of a brighter future will motivate people to go out and VOTE!!!!!<br /><br />I thought this video from The Onion was quite amusing, helps lower the blood pressure after listening to these debates!!<br /><br /><br /><embed src="http://www.theonion.com/content/themes/common/assets/videoplayer/flvplayer.swf" type="application/x-shockwave-flash" allowScriptAccess="always" wmode="transparent" width="400" height="355" flashvars="file=http://www.theonion.com/content/xml/84818/video&autostart=false&image=http://www.theonion.com/content/files/images/NEW_DEMOGRAPHICS_article.jpg&bufferlength=3&embedded=true&title=Latest%20Poll%20Reveals%20430%20New%20Demographics%20That%20Will%20Decide%20Election"></embed><br/><a href="http://www.theonion.com/content/video/latest_poll_reveals_430_new?utm_source=embedded_video">Latest Poll Reveals 430 New Demographics That Will Decide Election</a>Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/10/last-debate.htmltag:blogger.com,1999:blog-3208791370924468601.post-68511454479622008882008-10-06T09:21:00.000-07:002008-10-06T10:07:58.874-07:00drug samples in pediatric officesThis morning, as I was catching up on the news in between patients, an article in the NY Times caught my eye: <a href="http://tinyurl.com/42ttru">http://tinyurl.com/42ttru</a>. Upon seeing the title, I immediately thought the article would address the issue that drug samples do not come in child-proof containers; however, it actually addresses another serious issue with drug samples which is drug safety.<br /><br />The pharmaceutical industry gives samples to physicians generally of the latest, "greatest," most expensive drugs. These often have not been tested on pediatric populations yet. This is quite concerning when one considers some of the black box warnings which end up coming out, as happened with Elidel, among others. It is attractive, however, for physicians to use the samples they are given, but difficult for the family if the drug works and they then have large co-pays to cover. I have to admit that, working at a community health center, I don't see much in the way of pharmaceutical representatives, except for those representing immunizations. The majority of my patients have medicaid, so I stick with those formularies as much as possible.<br /><br />I would like to bring up the point I made earlier, though, and that is patient safety of sample packages. Our pharmacy encourages us to put all samples in child-resistant containers, print out a label like with a regular prescription, which has exact dosing on it, and to print out the drug information to hand the family with the sample. Now, if that sounds like a lot of work, it is, especially when I am the pharmacist dispensing the sample while seeing a full load of patients. Yet, I think it's worth the time to prevent an accidental ingestion. For example, one of the few samples I have is chewable Singulair. This comes in a foil push-out packet (I don't know the official term for this type of packaging). If a child gets a hold of one of these packets, it would be very easy to play with it and pop out one of the yummy pills...chomp chomp. Fortunately, this is not a terrible dangerous drug, but nonetheless... Do most offices dispense samples using this tedious process? Or is there a simpler way of doing it? I am open to suggestions. It just strikes me as odd in this litigious world we live in and especially as safety-conscious pediatricians, we allow this to continue. Perhaps we need to start bugging our friendly pharmaceutical reps! Any takers?Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/10/drug-samples-in-pediatric-offices.htmltag:blogger.com,1999:blog-3208791370924468601.post-58171022166040023532008-09-18T07:20:00.000-07:002008-09-18T08:04:46.132-07:00Investing in a turbulent stock market<a href="http://1.bp.blogspot.com/_wYVtLuqwDX8/SNJt7NZ4HvI/AAAAAAAAABk/vS7HhckooRE/s1600-h/market.jpg"><img id="BLOGGER_PHOTO_ID_5247377379817955058" style="FLOAT: left; MARGIN: 0px 10px 10px 0px; CURSOR: hand" alt="" src="http://1.bp.blogspot.com/_wYVtLuqwDX8/SNJt7NZ4HvI/AAAAAAAAABk/vS7HhckooRE/s320/market.jpg" border="0" /></a><br /><div>These are rough, interesting days on the stock market. Up until fairly recently, I was only vaguely aware of what was going on the market but didn't really think it affected me directly. I learned about the history of NYSE when I went to see it in action when I was still in elementary school, and it was still a very busy floor with men in suits running around like chickens with their heads cut off. I hear it's a bit different now with modernized computer systems! Then, as a senior in high school, we "traded" stocks for two weeks in my government class, buying stocks and following them in the newspaper. It was a fun game, or so I thought, again with no real consequences. I also remember Black Monday in 1987, talking about it in government class and seeing adults walking around with furrowed eyebrows. But I was a teenager who was more concerned about college applications and crushes on boys...</div><br /><div></div><br /><div>Come college, I happily took a variety of classes - there were so many interesting topics to choose from! I took language classes, geography classes, history classes, I even tried music theory, which I absolutely despised. I started off pre-med, so I also enrolled in chemistry and biology classes. I eventually became a French major, having tired of science classes. Did I ever take an economics class? No way. Sounded too boring. Perhaps if the department could have come up with some sexy titles to the courses, I might have, but I'm not even sure then because that was a section of classes in the course guide that I pretty much skipped over.</div><br /><div></div><br /><div>As you can guess, I eventually ended up in medical school. I attended a school with a very innovative curriculum which included a block at the end of our fourth year with classes relevant to residency, such as medical Spanish, yoga (to help us relax through those grueling intern years), and I honestly don't remember what else. We did have a lecture on paying off our loans which basically gave us the message to pay them off as rapidly as possible, to keep living like a resident after residency in order to make large payments on our loans. Certainly that was sage advice, but that was it for our financial education.</div><br /><div></div><br /><div>Needless to say, residency was about the same. Our daily noon conferences was excellent medical lectures. Each year we were given a talk on choosing a job which included learning about different types of malpractice, head hunters, and helping involve one's spouse in the decision. Very helpful, but again, not much about how to handle the money we were about to start making. Can you see a theme here? </div><br /><div></div><br /><div>So, I eventually landed in my first job. I signed on the dotted line to put the maximum amount of money I could into a retirement account because my parents had taught me that saving was a good thing. I chose the default funds to put my money into. For whatever reason, I didn't consult my husband on this choice, I think perhaps because I was overwhelmed by all the paperwork I had to fill out on my first day of work, and I figured that I was being guided in my investment decision by someone who knew more than me. And, as you can gather, I didn't know a whole lot. And my husband would have been an excellent resource.</div><br /><div></div><br /><div>Happily, the first few years, the economy was still relatively strong, although to an astute observer, there were signs of the current problems. As I started hearing about the stock market losing losing losing, I decided to take a look at my portfolio. Yikes. I had the feeling that this was going to be baptism by fire! The glorious 90s were over. Ignorance was bliss. Since then, I have made the effort to educate myself on the art of investing. I say art, because unless you are completely invested in index funds, there is an art to it. I just finished an informative book my father-in-law sent us called, "The Little Book of Common Sense Investing," by John Bogle, the founder of Vanguard. Although I prefer to read novels in bed after a long day of work, I read this book cover to cover. It was actually pretty interesting and well-written, without too much jargon for a lay person like me. Mr. Bogle focuses on the index fund, his own creation, which has gained many supporters in the financial fields. Basically, this is a fund that owns the entire stock market, thereby minimizing risk, and also, by owning a little bit of everything and not actively buying and selling stocks trying to guess who to invest in, there are low costs associated with it. This is investing for both the non-investor who doesn't have the time and/or skill and/or luck to buy and sell stocks daily, as well as financial wizards like Warren Buffett and John Bogle himself. It is a beautifully simple plan. And the book, although focusing on this particular type of fund, also teaches the reader about other types of investing. I highly recommend it. I obviously still have a long way to go, but I am an active learner now. Honestly, I would still rather read about neurofibromatosis than finances, but I also realize that I would eventually like to retire, preferably before the age of ninety...</div><br /><div></div><br /><div>The moral of this story is that perhaps some basic classes on investing could be incorporated somewhere into our education. The challenge is that there is just an amazing fount of knowledge we already have to acquire in medical school and residency. Where would this fit in? Maybe we could have quarterly lectures on it during residency or medical school. Many of us become physicians "to do good," not just to make money, and frankly, these days, there are other fields to go into to make money; but there is no reason we shouldn't have the resources to be wise with what we do take home. We work hard for our money, and it should work hard for us.</div>Alexnoreply@blogger.com3http://thepragmaticpediatrician.blogspot.com/2008/09/investing-in-turbulent-stock-market.htmltag:blogger.com,1999:blog-3208791370924468601.post-75652342237468635032008-09-12T15:30:00.001-07:002008-09-12T15:36:42.852-07:00not too muchJust a quick note from Colorado! I'm at my District VIII meeting, being awed by the work that pediatricians all over my district are doing. It's both inspiring and motivating to be surrounded by leaders in the field. It's also comforting to hear about the struggles they face that I too face, I am not alone!! I'll have lots to report when I get back, new resources, new websites, new ideas. For those of you who may not know what District VIII means, it is a district of the American Academy of Pediatrics, and it includes Alaska, Hawaii, British Columbia, Alberta, Washington, Oregon, Montana, Idaho, Utah, Wyoming, Nevada, Colorado, Arizona, New Mexico, and Uniformed Services West. It's the largest district geographically and obviously quite diverse.<br /><br />Sorry this is short, but I have limited time!Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/09/not-too-much.htmltag:blogger.com,1999:blog-3208791370924468601.post-77487007596312561552008-09-10T10:49:00.000-07:002008-09-10T12:25:15.954-07:00primary care shortageAll the buzz in the media and on doctor blogs in the past day or two has been the announcement that, according to a survey published in the Journal of American Medical Association, only 2 percent of graduating medical students are going into primary care, primarily due to poor salaries and increased workloads. <span style="color:#ff0000;"> TWO PERCENT!!!!!!</span><span style="color:#000000;"> </span><span style="color:#666666;">That is just frightening to think about, especially from the viewpoint of an already busy rural pediatrician. We, as primary care physicians, are already pushed to see as many patients as possible by our reimbursement schedules. I know that I am getting busier every season than I was the last. This year, my "slow" period consisted of approximately two weeks of slower days, then we picked right back, last year, my "slow" period lasted closer to one month; this year, I'm already seeing winter time numbers with school having been in session only for a few weeks....I'm afraid things will only get worse.</span><br /><br />How about talking about solutions to this problem?! Neither candidate is addressing this specific problems. Then again, nobody is really asking them to. I have a proposal: mandatory one to two year service in primary care medicine prior to specialization. In other countries such as New Zealand, they have general practitioners (GPs) who tend to the primary care needs of their citizens. Perhaps we could do something like that here in the US. I have just recently completed my service time for the National Health Service Corps and although that system is severely flawed, it could be used a loose guide. I am now free to do a fellowship, if I so desire. I've learned a lot from practicing this kind of remote primary care medicine, and I think this type of background would serve me well were I to do further training. <br /><br />This is by no means a perfect solution, and I'm sure I'm not the first to suggest it, but perhaps it could get people talking if it were put out on the table. I know that we, as physicians, already go through many years of training, and some would groan at an additional two years, but how else will we take care of an increasing population of baby boomers?? We cannot simply rely on foreign medical grads. We cannot rely on the whims of medical students. And, at least at this point, we cannot rely on improved salaries to draw medical students to primary care.Alexnoreply@blogger.com2http://thepragmaticpediatrician.blogspot.com/2008/09/primary-care-shortage.htmltag:blogger.com,1999:blog-3208791370924468601.post-70128001934708126492008-09-04T13:07:00.000-07:002008-09-06T13:22:27.355-07:00health careToday, I was reading another physician blog, <a href="http://acountrydoctorwrites.wordpress.com/">http://acountrydoctorwrites.wordpress.com/</a>, in between seeing patients (my charts were calling but I ignored them for the moment). One of his recent stories was entitled, "Choices in Swedish Health Care." In it, he discusses the socialized system of medicine in Sweden, a system somewhat similar to other socialized ones. This topic has been on my mind lately, especially with the election looming in November. Perhaps I shouldn't use the word "looming," but I am very concerned that a president will be elected who has not even mentioned the word <span class="blsp-spelling-corrected" id="SPELLING_ERROR_0">health care</span>.<br /><br /><br /><br /><br /><br />I spent one month working at a pediatric clinic/hospital in New Zealand in 2004, another country where everyone has basic <span class="blsp-spelling-corrected" id="SPELLING_ERROR_1">health care</span>. It is also somewhat tiered, in that there are some options for faster care through a private-payer system. One of the big problems there, as in Sweden, was waits. There is, however, a fairly strong medical tourism trade with Australia, especially for people needing radiation therapy for cancer; people who can afford to live temporarily in Australia are able to start their therapy more quickly. At the time I was there, these waits were being addressed by the government, so hopefully, things have improved.<br /><br /><br /><br /><br /><br />However, as we all know in the US, many people go without <span class="blsp-spelling-corrected" id="SPELLING_ERROR_2">health care</span> due to lack of health insurance. And, even those with insurance risk bankruptcy with a diagnosis of cancer, or a chronic health problem. We spend the most on <span class="blsp-spelling-corrected" id="SPELLING_ERROR_3">health care</span> of any first-world country, yet we have the poorest outcomes. What gives? Is that our technology is so advanced that we try to save those who likely would die in other countries? Is that our fees in <span class="blsp-spelling-corrected" id="SPELLING_ERROR_4">health care</span> are completely out-of-line with the rest of the world that we are just simply paying/charging too much? Is it the fault of the drug companies who make enormous profits are drugs that cost too much? I suspect it's a combination of all these and other factors.<br /><br /><br /><br />The bottom line, for me, is that if we, as a country, feel that <span class="blsp-spelling-corrected" id="SPELLING_ERROR_5">health care</span> is a right and not a privilege, we need to be willing to make sacrifices, to change how we as doctors are paid, and to change how we as consumers define <span class="blsp-spelling-corrected" id="SPELLING_ERROR_6">health care</span>.Alexnoreply@blogger.com1http://thepragmaticpediatrician.blogspot.com/2008/09/health-care.htmltag:blogger.com,1999:blog-3208791370924468601.post-47563493759950143292008-09-02T10:39:00.000-07:002008-09-02T12:13:19.713-07:00change is in the air<a href="http://4.bp.blogspot.com/_wYVtLuqwDX8/SL2QEsDix3I/AAAAAAAAABc/dqk3vauUnM4/s1600-h/leaves.jpg"><img id="BLOGGER_PHOTO_ID_5241503951549024114" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="http://4.bp.blogspot.com/_wYVtLuqwDX8/SL2QEsDix3I/AAAAAAAAABc/dqk3vauUnM4/s320/leaves.jpg" border="0" /></a><br /><div>I love this time of year. The sunlight is already beginning to have a fall quality to it, the air smells fresher, and the nights are cooler. Change is definitely in the air!</div><br /><div>When I first started this blog, I had plans to start a new job this coming winter, however, due to circumstances largely outside of my control, I will be continuing to practice here for a while. As you may know from reading my previous blogs, I do primarily outpatient care; our local hospital is ill-equipped for inpatient pediatric care. I worked hard as a resident to learn hospital medicine, and I'm afraid I'll lose those skills. So, I've decided to do some prn work as a hospitalist in Albuquerque. I am very excited about this, which is a little surprising to me, since I was very happy to leave the hospital as a resident. However, now that I've been away from that environment for some time, I really miss it! I had an interview last week, and it just brought this fact home to me. I like the challenge of these patients, I love the newborns, and it will be enjoyable to be around other pediatricians and pediatric support staff for a change. I think I'll learn a lot, I will refresh my skills, and I'll bring a unique perspective to the group, coming from a rural setting. I'm ready for this change/challenge.</div>Alexnoreply@blogger.com0http://thepragmaticpediatrician.blogspot.com/2008/09/change-is-in-air.html